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The Frayed Doctor-Patient Relationship

If you’re wearing a watch with a sweep-second hand, pause now and watch it click away 23 seconds. Researchers using hidden cameras and tape recorders in a number of primary care doctor’s offices demonstrated that this is the amount of time an average patient was allowed to describe her symptoms before she was interrupted by her doctor.

Unable to fully convey their needs, interrupted patients become victims of rapid-fire and often incorrect decision making, inappropriate tests, and prescription errors. They leave the doctor’s office feeling rushed and dissatisfied, maybe one symptom addressed but many questions still unanswered, told to save for another visit the other concerns they wanted to address.

You really ought to read this week’s (to me, long overdue) Newsweek article on the decline of the doctor-patient relationship. If you have time, check out the online comments–rants, actually–that follow.

It seems the days of Marcus Welby, MD, are long gone. You need to be a certain age to remember television’s kindly GP, who knew his patients as an extended family. Viewers liked Dr Welby because this was the way doctors once actually interacted with their patients, combining patience, insight, compassion, and honed clinical skills to make a diagnosis without the angst and psychodrama of today’s Dr House.

Managed care to blame?
The Newsweek article places the bulk of the blame for our current mess on the managed care system, the product of a for-profit health insurance industry. Over the past two decades, managed care has steadily eroded your physician’s income. Just to stay even (after all, office rent, payroll, and malpractice insurance cost more today), she’s added hundreds of new patients to her practice.

As a result, you get your 23 seconds and you’d better talk fast. You’re allowed one problem only–don’t bring a list. At the end you’re left adrift, and as you get your clothes back on you hear your doctor in the next room interrupting her next patient. Finally, if you’re lucky and do establish some form of a doctor-patient relationship, your employer changes insurers and you have to find a new doctor.

Managed care also places your doctor in the uncomfortable position of being the bad-guy nay-sayer. I probably repeat a “sorry, you-can’t-have-that-because-your-insurance-won’t-cover” phrase ten times daily regarding diagnostic tests, surgical procedures, medications, and other therapies.

Occupations that deal primarily with people can be divided in two groups: the helping professions, the “yes you can” group (doctors, teachers, social workers), and the hindering professions, the “no you can’t” group (inspectors, auditors, all bureaucrats).

We doctors are not pleased with managed care turning us from helpers into hinderers.

Currently, an average primary care practice follows about 2,300 patients, up from 1,800 20 years ago and 1,500 in Dr Welby’s era. Based on recommended practice guidelines, doing all the right things for 2,300 patients will take a physician 17 hours a day, so he hires personnel (which he frequently can’t afford) to offload some of the non-medical work. Behind the scenes in a doctor’s office, you’d be struck dumb by the amount of time spent dealing with insurance companies: on the phone, copying records, filling out forms, writing letters trying to get services approved and medications authorized, trying to get paid for medical care provided weeks or months earlier.

The result–“life on a hamster wheel” as one doctor reported–has made primary care (which includes family practice, internal medicine, pediatrics, and obstetrics-gynecology) generally undesirable specialties. Instead, American medicine is awash with specialists and because our healthcare system financially rewards procedures most generously, you’re all getting far more surgery and invasive diagnostic tests than you really need.

Financially well-off patients (America’s one percenters) have the option of entering a so-called concierge practice where you essentially buy your own Marcus Welby. A concierge physician is a primary care doctor who has chosen to return to Welby-era medicine, though a concierge practice is even smaller than Dr Welby’s.

Obviously, this is not the answer for the rest of us.

Encouraging trends
The situation is far from hopeless, however, and there are some encouraging trends.

Some medical schools are moving beyond “top grades” when selecting new students, ensuring that prospective students are also good people-persons. Some schools have introduced a “doctoring curriculum” that teaches communication skills. Some practices are bringing in more ancillary staff, including nurse practitioners and physician assistants, to treat conditions that really don’t require an MD. Other practices (unfortunately not enough) like our WholeHealth Chicago have a team that integrates conventional and alternative practitioners.

In addition, the internet has allowed patients themselves to become pro-active in their health care. They can read reviews of physicians (and their dry cleaners too) on angieslist.com and yelp.com and google their own health concerns to learn about symptoms and treatment. Online patient support groups, too, have exploded.

As a final word, I must say that chiropractors are generally much better than medical doctors at personal interaction with patients. This is because relationship-building has been a part of their school curriculum for decades. The following list, created by a medical think tank/policy group in Washington, DC, called the Institute for Patient- and Family-Centered Care, appeared in this month’s Journal of the American Chiropractic Association and was sent to me by my chiropractic associate Dr. Paul Rubin.

Top Ten Quality Indicators of an Effective Patient- and Family-Centered Physician

1. Listens to all symptoms before making a diagnosis.
2. Is knowledgeable about the patient’s condition–past and current status.
3. Is very knowledgeable about diagnosis and current treatments, staying up to date on current evidence and recent research.
4. Encourages patients and family members to ask questions and participate in the care experience.
5. Gives options for solving problems and suggests ways in which patient and family members can participate in care.
6. Collaborates with patient and family member in seeking additional solutions.
7. Volunteers information about agencies that provide additional services and knows how to access those services.
8. Uses familiar terminology or carefully defines new terms; checks to ensure that the patient and family members understand.
9. Takes time and does not seem rushed.
10. Follows through on care and outcomes.

Finding doctors like this is not impossible, but may require a little hunting. Just getting yourself beyond that first 23 seconds will make the effort worthwhile.

I just wanted to say that you are very patient-centered. I felt really good and was very impressed the first time I came to see you, how much time you spent with me that day. Until now I continue to feel the satisfaction of being cared for. Thank you for the wonderful care!

I’d like to say the same, Dr. E. After my first appointment, I told people who asked, “He spent over an hour with me! What a nice change.” Thanks for finding a way around the norm and treating your patients so well. I feel very fortunate to have found you!

thanks for this article. The public is certainly not aware of the volume of activities involved with medical practice. In addition to those you mentioned regarding billing, electronic medical records are new to the majority of US doctors. Many still write notes or dictate. Now, faced with learning how to make computerized notes, many are overwhelmed and are found in their offices late into the night.

There is a solution to this crisis. It is called boutique or concierge medicine. Some also call it Dr. Welby medicine. Under this style of medicine you restore the patient and doctor relationship. You see the doctor and the patient pays cash for his or her services. The doctor gives the patient time 15 to 30 minutes depending on the reason for the visit. This way the patient gets his or her needs met and does not get a five minute visit (if you are lucky to get that much time) as is the practice today.

For large medical expenses (Cancer, ALS, major surgery, etc.) you have insurance that will help you pay for that. We must get insurance companies and HMO’s as far away as possible from the medical process. Our health depends on it.

Hi
Actually you’re not describing concierge medicine but rather good old fashioned fee-for-service (FFS) medicine. Obviously, there’s nothing basically wrong with FSS medicine if you have the $$ for the fee. Some doctors here in Chicago routinely charge $175 to $300 for an office visit and unless you’ve received a trust from your parents, you can quickly run out of money if you have to see the doctor regularly. Moreover, this FFS model does not cover lab tests or x rays.
With concierge (boutique) medicine, you agree to pay an annual fee (usualy $1.500 to $3,000 a year) for unlimited office visits, phone consults, etc. Again, if money is no object then a patient might like this kind of service. We at WholeHealth Chicago have a philosophical issue with concierge medicine in that it further emphasizes the have versus have not two-tier component of our existing system.

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